197608685-4-26-2022-31-AS-NMAN-CEKUX9-20220519155754

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608685
Report Date: 04/26/2022
Date Signed: 04/26/2022 04:42:14 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/21/2020 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20200521113557

FACILITY NAME:	ATRIA SANTA CLARITA		FACILITY NUMBER:	197608685
ADMINISTRATOR:	JOHNNY ORTIZ		FACILITY TYPE:	740
ADDRESS:	24431 LYONS AVE		TELEPHONE:	(661) 254-9933
CITY:	SANTA CLARITA	STATE: CA	ZIP CODE:	91321
CAPACITY:	160	CENSUS: 98	DATE:	04/26/2022
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Johnny Ortiz		TIME COMPLETED:	11:47 AM

ALLEGATION(S):

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Staff did not seek timely medical care for resident.
Facility has C diff contamination.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. Upon entry, LPA met with Executive Director (ED), Johnny Ortiz, and explained the reason for the visit.

--- Staff did not seek timely medical care for resident.

It was alleged that the facility did not seek timely medical attention for Resident #1 (R1). To investigate this allegation on 04/06/2022 LPA interviewed staff and requested pertinent documents from 11:00 AM - 2:20 PM. Interviews and record reviews revealed that the facility staff completed a Notice of Change in Condition on 05/03/2020, 05/06/2020 and 05/11/2020 and faxed them to the physician at HealthCare Partners Medical Group and Affiliated Physicians.

(Cont. on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20200521113557

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ATRIA SANTA CLARITA	FACILITY NUMBER: 197608685
	VISIT DATE: 04/26/2022

NARRATIVE

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Interviews revealed that staff notified R1’s physician about the loss of appetite, decreased fluid intake and loose stool and that the physician’s response was, “no update in medications or care needed at this time”. Subsequently, Staff #1 (S1) was notified of R1’s rapid decline and immediately called 911.

Based on the interviews and record reviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Facility has C diff contamination.

It was alleged that R1 got the infection from staff or other residents and since residents share bathrooms, it is highly likely that the facility has more cases of C diff. To investigate this allegation on 04/06/2022 LPA conducted a physical plant tour at 10:00 AM, interviewed staff and requested pertinent documents from 11:00 AM - 2:20 PM. Interviews, record review and observations revealed that there were no other cases of C diff during R1’s time at the facility. LPA observed R1’s room and R2’s room, whom which R1 shared a restroom with. Record reviews revealed that R2 did not have C diff before or after R1 was admitted. Record reviews and interviews further revealed that neither staff nor residents contracted C diff during R1’s time at the facility.

Based on the interviews, record reviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards were noted during the visit.

Exit interview was conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

LIC9099 (FAS) - (06/04)

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